Encopresis refers to fecal incontinence that occurs at least once a month in children 4 years of age and older. Encopresis is non-organically based and therefore organic conditions resulting in fecal incontinence must be ruled out before making diagnosis of encopresis.
The clinical case reported here was first reported in Knell & Moore, 1990, and is also described in the book “Cognitive Behavioral Play Therapy”, by Susan M. Knell (1993, 1998).
It describes the treatment of a child, with primary non-retentive functional encopresis, through play sessions structured on a cognitive-behavioral play therapy model, in association with a behavioral management program.
The description of treatment highlights ongoing therapy, how to regulate the child’s emotions as they relate to his encorpresis, and follow-up.
Case description
Terry was an almost 51/2-years-old Caucasian boy, who presented with primary functional non-retentive encopresis. He was the firstborn of a set of male triplets, and the most quiet and passive. He had told his parents that he did not want to be like his brothers, and according to parental report became upset when people could not tell them apart.
An intellectual evaluation completed by the school psychologist indicated he was in the average range of intelligence (Standford-Binet IQ= 103), although he did have developmental expressive and articulation language disorders. After a medical work-up revealed no organic etiology for the soiling, Terry’s pediatrician referred the family to a child psychologist. Terry had no other known medical or psychological conditions.
Assessment with parents
In the initial interview, Terry’s parents reported that he soiled several times daily, and if not changed by an adult, he would remain in soiled pants. No history of constipation was reported. The child had been minimally responsive to medical interventions (e.g., diet modifications).
All efforts to train Terry to use the toilet for bowel movements were unsuccessful, although he successfully had been trained to use the toilet for urination at age 3 years. The parents felt that Terry was not afraid of using the toilet, based on their observations and his comments. However, he had told them that he did not want to learn to use the toilet and be “like his brothers”, both of whom were completely toilet trained. The parents were asked to keep records of Terry’s toileting/soiling for 12 days.
During this collection of baseline data, the parents checked Terry’s pants for evidence of soiling at four specific times (12.30; 15.30; 18.30 and bedtime). Soiling was defined as evidence of any fecal material or fresh discoloration of the underpants. The parents were instructed to remain neutral in interacting with him while checking his pants and merely explained to him that they needed to see “if his pants were clean or soiled”. Any soiling that occurred during these intervals was recorded at the prescribed times.
Assessment with child
Assessment with Terry consisted of structured play sessions in which the topic of soiling was introduced through a toy bear who “pooped his pants” (Terry’s words as described to the therapist by his parents). The therapist made note of Terry’s reactions to the toy bear and the information Terry brought spontaneously into the play situation. In reality, assessment took place throughout the course of treatment as Terry brought to the sessions new information that was used to understand his perceptions about his soiling. Because of limitations in his expressive language, Terry was not directly interviewed. With the exception of the intelligence measures given independently, no other specific testing was done.
Treatment
Treatment consisted of 15 sessions, once a week, which took place over the course of 132 days. Cognitive-behavioral play therapy was used with the child, simultaneously with a work with the parents on the behavioral management of the child’s encopresis. The parents were seen in the first part of the session, in order to use the information received from them in therapy with the child.
The CBPT was initiated after the collection of baseline data.
Initially, the sessions consisted primarily of observing the child playing spontaneously. Structured, directive behavioral interventions were incorporated into a nondirective play therapy approach.
The therapist systematically took specific themes from the child’s play and structured cognitive-behavioral interventions to address these issues. In particular, the therapist utilized a toy bear who soiled its pants and did not use the toilet.
Structured situations were created with the teddy bear that were yoked to the child’s contingency management program. The bear went through a “contingency management program” in the sessions, where he received stars and praise for appropriate toileting and dry pants; gradually the child began competing with the bear, comparing numbers of stars and expressing his wish to “beat the bear”. Terry’s behavioral responses were also addressed in such a way that the therapist helped to put words to his feelings (e.g., instead of hitting the bear, he could tell the bear he was angry that the bear was getting more stickers than he was).
Several themes addressed during the treatment were: fear of the toilet, increasing child’s sense of mastery of toileting and facilitating appropriate expression of feelings.
The behavioral management program implemented by the parents began at the same time as the CBPT with the child. This intervention consisted primarily of a sticker program in which the child was reinforced for non soiled pants and appropriate toilet use. To encourage toilet use, Terry was placed on the toilet for 10 minutes three times per day at approximately ½ hour after each meal. When he was soiled, the parents gently reminded him that he needed to clean himself and change his underpants. He was taught to do this task in such a way that he needed minimal assistance from a parent.
By week 8, the child’s soiling had decreased. However, Terry had still had not had a bowel movement on the toilet. To avoid fecal impaction, it was necessary to give him three enemas over the course of 9 days. He apparently responded well to the enema and was quite happy after each bowel movement in the toilet.
Results
Positive results were reported. The child was soiling during the baseline period approximately 77 percent of the time. Soiling steadily diminished and between the twelfth and fourteenth sessions he had only three accidents. Terry wasn’t soiling after the fourteenth session (110 days from the start of treatment). Regarding the treatment, during the first 8 sessions (63 days), Terry did not use the toilet for bowel movements. After the twelfth session, Terry spontaneously and regularly used it.
Follow-up
Terry was monitored for 45 months after the end of treatment through contact with parents. They reported that Terry had no other psychological or medical problems.
Conclusions
Most interventions with pre-school encopretic children focus on managing the child’s behavior without addressing his or her cognitions and emotions.
Through CBPT Terry was able to directly identify his anger and modify the cognitive distortions associated with it. Encopresis is a complex and multifactorial disorder, so there is the possibility that differential treatments are required for different types of encopresis (Doleys, 1983). The possibility of applying only CBPT for the treatment of the encopretic child was not adopted. Although, CBPT alone was not used (ie it was combined with a behavioral management program), it is most likely that the combination of interventions contributed to the effectiveness of the treatment.
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